START YOUR APPLICATION

Apply for funding

Tell us about yourself, your claim, your medical care and your lawyer. No account or password is required. Your lawyer will confirm the underwriting information after our team reviews your application.

* Required. Choose Not sure if you do not know an answer. Please do not enter Social Security numbers or banking information. Brief medical summaries are enough; reports can be supplied by your lawyer through the private portal.

Your information

First name *Middle initialLast name *Email address *Phone number *Date of birthOptional here; your lawyer will confirm it during underwriting.

Your Claim

Date of loss / incident *State where the claim arose *CountyCase/claim number, if availableType of claim *Funding amount requested ($) *Briefly describe what happened *A short description is enough.

First medical visit

Where did you first receive medical care for this incident? *Date of first medical visit, if knownProvider / ER / hospital / facility name, if known

Prior funding

Have you already received funding for this claim? *Have you applied for funding for this claim with another company? *

Pictures and reports

Do you have pictures related to the incident or your injuries? *Do you have an incident report? *Do you have a police report? *

Damages — injuries and medical care

Tell us about care related to this incident. Brief descriptions are sufficient. Include planned care in the details if applicable.

Injuries / affected areas, if knownHave you received an MRI? *Have you received any medical treatment? *Have you had any medical procedures? *Have you had any surgeries? *Do you have any medical reports or records? *

Your handling lawyer

Lawyer first name *Lawyer last name *Law firm *Lawyer’s individual emailUse the handling lawyer’s email if known. Our team will verify it before providing access.Lawyer / firm phone *

Your application is used for underwriting review. It is not a funding agreement or approval. No fee is collected when you submit this form.